Provider Demographics
NPI:1124130034
Name:MOUNTAIN RX LLC
Entity type:Organization
Organization Name:MOUNTAIN RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:540-777-7500
Mailing Address - Street 1:3324 WILLIAMSON RD NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-4058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3324 WILLIAMSON RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-4058
Practice Address - Country:US
Practice Address - Phone:540-777-7500
Practice Address - Fax:540-777-7504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003650333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4834431OtherNCPDP #
4834431OtherOTHER ID NUMBER-COMMERCIAL NUMBER
VA8519111Medicaid
VA8519111Medicaid
VA4834431OtherNCPDP #